Rates of women who are opting for preventive mastectomies, such as Angeline Jolie, have increased by an estimated 50 percent in recent years, experts say. But many doctors are puzzled because the operation doesn't carry a 100 percent guarantee, it's major surgery -- and women have other options, from a once-a-day pill to careful monitoring.

First, the vaccine is not cheap. Merck says the cost will probably be about $300. That raises three key questions: who to vaccinate, when and who will pay?

Every year cervical cancer kills about 3,700 American women. Cervical cancer is now known to be caused by a virus, the human papilloma virus (HPV), which is transmitted through intimate sexual activity.

Both men and women carry the virus but obviously only women get cervical cancer. So the first priority from a public health point of view is to focus on vaccinating women.

One unknown is how long the new vaccine will protect against the nasty strains of HPV. The best estimate is five years.

This means the best time to vaccinate is just before women become sexually active. And that is why this new cervical cancer vaccine is sure to be ethically controversial.

Some conservative religious groups and family-values advocates believe that the best way to prevent any sexually transmitted disease is to teach young people to be abstinent until marriage. They don’t want HPV vaccine offered to young women because it will encourage, in their view, sexual promiscuity. Or they only want the vaccine discussed by parents not in schools or in the doctor’s office. But there is a big flaw in this reasoning.

Even though a woman may remain chaste until marriage she may marry someone who wasn’t. She would still be at risk of infection. Given that risk, the case for getting schools, doctors, public health departments involved even if you are someone who wants to keep all talk of sex in the home starts to become very strong.

Who decides?
That leads to the next big ethical question the new vaccine raises. If it is young women who can benefit the most from getting vaccinated, then should HPV vaccination be mandatory or voluntary. And should a young woman have the right to decide for herself if she wants the vaccine or should her parents decide? Or should everyone be involved?

Pediatricians, other physicians, public health officials and nurses who provide medical care to teenage girls will now have to answer these questions.

In most states, doctors are legally permitted to prescribe contraceptives to adolescent girls who specifically ask that their parents not be informed. Doctors are also legally permitted to treat sexually transmitted infections in teenage patients without their parents’ permission. The rationale in both cases is the same. From a public health perspective, it is better for doctors to be able to help all sexually active teenagers prevent unwanted pregnancies and sexually transmitted infections, including those girls who would not seek medical care if parental permission was required. Shouldn’t we treat the new HPV vaccine the same way? I think so.

Right now, doctors must have a parent’s consent to administer a vaccination. What should a doctor do when her 14-year-old patient whom she has been taking care of since she was a toddler comes for a visit without her mother and says she may become sexually active with her boyfriend? The best thing to do is to make sure the girl gets the vaccine. Legally, however, the doctor cannot administer HPV or any vaccine without a parent’s consent. Knowing what teenagers are like do we want to continue to insist that parental permission is always required when it comes to HPV vaccine? I don’t think so.

Suppose we can agree that every young woman should get vaccinated against HPV. And we might even agree that parental permission ought to be required unless the young woman seeks out the vaccine on her own and directly requests that her parents not be told. One huge problem still remains. Who is going to pay for all these shots?

Footing the bill
Vaccinating all women say at the age of 12 in the United States is beyond the budgets of nearly every city and state health departments. And many health insurers don’t pay for vaccinations. Will only rich Americans who can pay out-of-pocket have access to the new vaccine? Ironically that is precisely the group that needs the vaccine the least since they are already probably getting their daughters good gynecological care including regular Pap smears.

And just to give the cost problem its due, HPV is not confined to America. It is an even bigger problem overseas. In sub-Saharan Africa, South Asia, and Latin America, HPV is the No. 1 cause of cancer deaths among women. In these regions, women often receive no treatment for cancer and suffer terribly before dying. Who is going to pay the costs of vaccinating the young women of India, Africa and Latin America?

Medicine is poised to take a giant leap forward in the war on cervical cancer. But every American needs to think hard about the challenge this medical opportunity creates. The issue of cervical cancer vaccine will soon come to your school, church, synagogue, mosque and doctor’s office. The right thing to do is to ensure as best we can that all young women are vaccinated. Now is the time to push politicians to make sure that the money will be there to make this happen. If insurance companies don’t have to pay and public health departments cannot afford to then all the other moral issues surrounding this new vaccine become moot. It's time to prevent that from happening.

Arthur Caplan, Ph.D., is director of the Center for Bioethics at the University of Pennsylvania.